Claudia Sannibale

Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial.

CONTEXT There is concern that exposure therapy, an evidence-based cognitive-behavioral treatment for posttraumatic stress disorder (PTSD), may be inappropriate because of risk of relapse for patients with co-occurring substance dependence. OBJECTIVE To determine whether an integrated treatment for PTSD and substance dependence, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), can achieve greater reductions in PTSD and substance dependence symptom severity compared with usual treatment for substance dependence. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial enrolling 103 participants who met DSM-IV-TR criteria for both PTSD and substance dependence. Participants were recruited from 2007-2009 in Sydney, Australia; outcomes were assessed at 9 months postbaseline, with interim measures collected at 6 weeks and 3 months postbaseline. INTERVENTIONS Participants were randomized to receive COPE plus usual treatment (n = 55) or usual treatment alone (control) (n = 48). COPE consists of 13 individual 90-minute sessions (ie, 19.5 hours) with a clinical psychologist. MAIN OUTCOME MEASURES Change in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale (CAPS; scale range, 0-240) and change in severity of substance dependence as measured by the number of dependence criteria met according to the Composite International Diagnostic Interview version 3.0 (CIDI; range, 0-7), from baseline to 9-month follow-up. A change of 15 points on the CAPS scale and 1 dependence criterion on the CIDI were considered clinically significant. RESULTS From baseline to 9-month follow-up, significant reductions in PTSD symptom severity were found for both the treatment group (mean difference, -38.24 [95% CI, -47.93 to -28.54]) and the control group (mean difference, -22.14 [95% CI, -30.33 to -13.95]); however, the treatment group demonstrated a significantly greater reduction in PTSD symptom severity (mean difference, -16.09 [95% CI, -29.00 to -3.19]). No significant between-group difference was found in relation to improvement in severity of substance dependence (0.43 vs 0.52; incidence rate ratio, 0.85 [95% CI, 0.60 to 1.21), nor were there any significant between-group differences in relation to changes in substance use, depression, or anxiety. CONCLUSION Among patients with PTSD and substance dependence, the combined use of COPE plus usual treatment, compared with usual treatment alone, resulted in improvement in PTSD symptom severity without an increase in severity of substance dependence. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN12908171.

Do acamprosate or naltrexone have an effect on daily drinking by reducing craving for alcohol

AIM To explore the effect of acamprosate and naltrexone on craving and alcohol consumption in the treatment of alcohol dependence. DESIGN A randomized, double-blind, single-dummy, placebo-controlled trial. SETTING Three treatment centres in Sydney, Australia. PARTICIPANTS A total of 169 alcohol-dependent subjects were given naltrexone (50 mg/day), acamprosate (1998 mg/day) or placebo for 12 weeks, in conjunction with manualized medication compliance therapy. INTERVENTION During the course of the trial, participants kept a daily diary which included the number of standard drinks they consumed and their peak craving for alcohol that day rated on a 0-10 scale. MEASUREMENTS Subjective ratings of daily craving and daily drinking for the first 6 weeks of treatment. FINDINGS Mixed/hierarchical linear models were employed on an intention-to-treat basis. Analyses revealed that craving was a significant predictor of daily drinking and baseline levels of depression were the best predictor of daily craving. There was no significant improvement in model fit when treatment group was added both in models of daily craving and daily drinking. Daily alcohol consumption was best predicted by a model incorporating baseline dependence and depression scores, and daily craving, entered as a time-varying covariate. However, there was a significant craving x time x treatment interaction (t = -3.365, df = 4413.712, P < 0.001), suggesting that at higher levels of craving drinking was reduced at a significantly greater rate with naltrexone compared to acamprosate. CONCLUSIONS Naltrexone had a greater effect on drinking when craving was high. These results support the role of naltrexone in reducing craving when that craving is highly salient. The role of acamprosate in reducing craving was not supported by these findings.

The efficacy of diversion and aftercare strategies for adult drug-involved offenders: a summary and methodological review of the outcome literature

Diversion strategies aim to redirect drug-involved offenders away from the criminal justice system and into treatment. Despite the interest in diversionary practices, the emergence of an empirical evaluation literature has been slow. A methodological review of published outcome studies was conducted to investigate the current strength of evidence for the efficacy of diversion and aftercare practices for criminal offenders. Twenty outcome studies were identified for review: 19 on diversion and one on aftercare. The vast majority of studies were non-randomised evaluations, reflecting the paucity of rigorous evaluation work in this area. Although most studies were prospective, very few reported on long-term outcomes following treatment. Detail was lacking with regard to basic study characteristics, such as eligibility criteria and outcomes. Despite these methodological shortcomings, results provide some tentative evidence that diversion and aftercare programmes could be effective. Best practice elements of diversion and aftercare programmes are identified and feasible strategies to improve the methodological quality of future evaluations are considered.

Childhood trauma among individuals with co-morbid substance use and post traumatic stress disorder

BACKGROUND: Little is known about the impact of childhood trauma (CT) on the clinical profile of individuals with co-occurring substance use disorder (SUD) and post traumatic stress disorder (PTSD). AIMS: To compare the clinical characteristics of individuals with SUD+PTSD who have a history of CT with SUD+PTSD individuals who have experienced trauma during adulthood only. METHOD: Data were collected on 103 individuals as part of a randomised controlled trial examining the efficacy of an integrated psychosocial treatment for SUD+PTSD. Participants were recruited from substance use treatment services, community referrals and advertising. Data were collected on demographic characteristics, substance use and treatment histories, lifetime trauma exposure, and current physical and mental health functioning. RESULTS: The vast majority (77%) of the sample had experienced at least one trauma before the age of 16, with 55% of those endorsing childhood sexual abuse. As expected individuals with a CT history, as compared to without, evidenced significantly longer duration of PTSD. Those with a CT history also had more extensive lifetime trauma exposure, an earlier age of first intoxication, and reported more severe substance use (e.g., a greater number of drug classes used in their lifetime, higher severity of dependence scores and greater number of drug treatment episodes). CONCLUSION: Individuals with co-morbid SUD+PTSD who have experienced CT present with a more severe and chronic clinical profile in relation to a number of trauma and substance use characteristics, when compared to individuals with adulthood only trauma histories. It is therefore important for SUD+PTSD treatment planning that CT be carefully assessed.

Issues with recruitment to randomised controlled trials in the drug and alcohol field: a literature review and Australian case study.

ISSUES The randomised control trial (RCT) is a widely used tool for measuring the effectiveness of health treatments and services. However, subject recruitment is an ongoing challenge for those conducting RCTs and may have a serious impact on the success of the study and the reliability of the outcomes. APPROACH In this review we present an examination of the problems and strategies associated with recruitment to RCTs, with particular reference to studies conducted in the drug and alcohol field. A case study of recruitment to an RCT for the treatment of alcohol dependence is presented, supplemented by PubMed, Current Contents and Medline searches to identify relevant publications. KEY FINDINGS The literature suggests that the most common barriers to patient participation involve fears of assignment to placebo treatment, insufficient compensation and poor attendance at initial appointments. Moreover, subject referrals from staff may be a greater problem than reluctance of patients. Referrals are inhibited by complicated entry criteria, time constraints due to busy work schedules or a limited research culture. IMPLICATIONS Subject recruitment may be promoted by financial reimbursement, close partnerships between research and referral staff; increasing the treatment group ratio in multi-drug trials to minimise randomisation to placebo; addressing negative staff attitudes; and simplifying the referral process. CONCLUSION The need for multi-centre sites in Australian drug and alcohol treatment studies is highlighted.

Some new directions for research on psychological interventions for comorbid anxiety and substance use disorders

ISSUES Comorbidity between anxiety and substance use disorders is common, yet it is poorly understood and poorly treated. APPROACH Narrative literature review. PsycINFO and Medline databases were searched for clinical trials of anxiety and substance use disorders using clinical queries for 2005-2009. KEY FINDINGS There are few well-conducted treatment outcome trials for comorbid anxiety and substance use disorders. Some recent (2005-2009) outcome literature has focused on specific mechanisms (anxiety sensitivity and tension reduction alcohol expectancies) that may underlie comorbidity between anxiety and substance use disorders and may lead to more targeted intervention. IMPLICATIONS AND CONCLUSION: The research base for understanding and treating comorbid anxiety and substance use disorders needs to be broadened. In particular research is needed with a focus on: (i) specifying particular comorbid relationships between anxiety and substance use disorders; (ii) the mechanisms that may underlie and maintain those relationships; and (iii) well-conducted evaluations of treatments that target those mechanisms.

The differential effect of a set of brief interventions on the functioning of a group of “early-stage” problem drinkers

The present study evaluated the effectiveness of different treatment conditions on the functioning of a group of male problem drinkers (N = 96) presenting to a community agency for treatment. Clients were randomly assigned to one of three treatment conditions and assessed before treatment and again a minimum of twelve months after using a number of drinking and non-drinking-related measures of functioning. Corroborative information was obtained from a person nominated by each client. Contact was maintained with clients and their collaterals throughout the follow-up period. Follow-up assessment data were available for 80 (83%) clients; and collateral information for 84 (88%) clients. At follow-up, using self-report data, 38 clients (40% of initial sample) were classified as improved, 5 were abstinent and 33 non-problem drinkers. Analyses of variance and discriminant analyses were used to ascertain the effects of treatment on client status at follow-up. Treatment was not found to exert a differential effect...

Is specialized integrated treatment for comorbid anxiety, depression and alcohol dependence better than treatment as usual in a public hospital setting?

AIM To assess the effectiveness of a 12 week specialized, integrated intervention for alcohol dependence with comorbid anxiety and/or mood disorder using a randomized design in an outpatient hospital setting. METHODS Out of 86 patients meeting the inclusion criteria for alcohol dependence with suspicion of comorbid anxiety and/or depressive disorder, 57 completed a 3-week stabilization period (abstinence or significantly reduced consumption). Of these patients, 37 (65%) met a formal diagnostic assessment of an anxiety and/or depressive disorder and were randomized to either (a) integrated intervention (cognitive behavioural therapy) for alcohol, anxiety and/or depression, or (b) usual counselling care for alcohol problems. RESULTS Intention-to-treat analyses revealed a beneficial treatment effect of integrated treatment relative to usual counselling care for the number of days to relapse (χ(2) = 6.42, P < 0.05) and lapse (χ(2) = 10.73, P < 0.01). In addition, there was a significant interaction effect of treatment and time for percentage days of abstinence (P < 0.05). For heavy drinking days, the treatment effect was mediated by changes in DASS anxiety (P < 0.05). There were no significant treatment interaction effects for DASS depression or anxiety symptoms. CONCLUSIONS These results provide support for integrated care in improving drinking outcomes for patients with alcohol dependence and comorbid depression/anxiety disorder. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01941693.

Process evaluation of an out-patient detoxification service

This paper describes the process evaluation of an out-patient detoxification service (ODS) established by Drug Health Services (DHS) to increase the supervised withdrawal options for substance users in a Sydney metropolitan Area Health Service. The ODS aimed to provide a safe and effective supervised withdrawal to substance users who were at low risk of severe withdrawal, engage those with severe dependence in further treatment and increase the involvement of general practitioners (GPs) in the medical care of ODS clients. During its first 10 months of operation, the ODS received 199 inquiries, assessed 82 individuals and admitted 76 clients for detoxification. Withdrawal treatment proceeded without complications and within the expected time frames. Fifty-four clients completed withdrawal, 10 ceased treatment, 10 remained in treatment without completing withdrawal and two were transferred elsewhere. Clients who injected substances (mainly heroin) daily at admission, compared to others, were less likely to complete withdrawal and more likely to use a range of non-prescribed substances during withdrawal. One-fifth of clients went on to further treatment with DHS, attending at least once. Overall, the ODS met its goals, providing a safe and effective supervised withdrawal to local residents, especially women, young people and those withdrawing from benzodiazepines who had significant substance dependence, impairment and previous alcohol and other drug (AOD) treatment. Non-injecting substance users benefited most from the ODS in terms of withdrawal completion and ongoing treatment. The level of GP involvement in the conjoint care of ODS clients remained constant over time. The development and expansion of the ODS are discussed.

ARE THERE TWO TYPES OF ALCOHOLISM

n 1981 Cloninger and colleagues1 derived a binary typology of alcoholism from studies of the disorder among children of alcoholic and non-alcoholic parents who were adopted shortly after birth in Sweden. Type 1 alcoholism occurred in both men and women, usually starting at an early age, affecting individuals with few social and legal problems, and causing either mild or severe alcohol dependence. Type 2 alcoholism occurred predominantly in men, among whom age at onset was earlier than that among type 1 alcoholics; type 2 individuals were more likely than type 1 to have social and legal problems, and dependence was usually moderate. In addition, type 2 alcoholism had a much higher heritability than did type 1 alcoholism, which was expressed in severe form only if the adoptee was placed in certain types of adoptive families.